Epidural and Intrathecal Analgesia
Pamela E. Macintyre, Stephan A. Schug in Acute Pain Management, 2021
Generalized sepsis or significant foci of infection in other parts of the body may increase the risk of an epidural space infection, and placement of an epidural catheter in such patients remains controversial. The positioning of the epidural catheter is therefore as important for lipid-soluble opioids as it is for local anesthetics. As with epidural hematomas, epidural space infections often occur spontaneously and unrelated to epidural analgesia, usually as the result of hematogenous spread of bacteria, in particular in IV drug users. Patients with severe increasing back pain after epidural catheter placement should be investigated promptly, even in the absence of a fever. If an epidural space infection if suspected, and the epidural catheter is still in place, it should be removed and the catheter tip sent for culture as well as appropriate blood tests and cultures ordered. The epidural catheter insertion site should be inspected daily and note made of the patient's temperature.
Tumors of the Nervous System
Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw in Hankey's Clinical Neurology, 2020
Neoplasms of the nervous system may be categorized into those that derive from cells of the brain, spinal cord, and peripheral nerve (primary tumors) and those that have metastasized to the central nervous system (CNS) from nonneural tissues. Metastatic tumors of the nervous system are more common than malignant brain and spinal cord tumors. Brain tumors account for 2% of all cancers but produce disproportionate morbidity and mortality when compared with other malignancies. Systemic malignancies may metastasize to the brain and cord parenchyma, leptomeninges, dura, and epidural space. Increased incidence may also be due to longer survival, as a result of improved systemic therapies with incomplete CNS penetration, creating sanctuary sites in the brain parenchyma and leptomeninges. According to the Monro–Kellie doctrine, brain parenchyma, blood, and cerebrospinal fluid occupy the fixed volume of the cranium. Increase in the volume of one compartment requires a compensatory decrease in the others.
Spinal and Epidural Anaesthesia
T.M. Craft, P.M. Upton in Key Topics In Anaesthesia, 2021
Spinal and epidural anaesthesia using local anaesthetics can produce profound analgesia, muscle relaxation, and a reduction in operative blood loss. Analgesia may also be provided by other agents injected into the cerebral spinal fluid (CSF) or epidural space. Neuroaxial anaesthesia is most effective when the site of is close to the affected dermatomes. Spinal or epidural anaesthesia may be considered for any operation to the lower limbs, perineum or lower abdomen. There are certain circumstances where it is especially indicated either with or without general anaesthesia. Spinal anaesthesia in particular is not a safe technique in those with cardiovascular disease such as fixed cardiac output states. Local anaesthetic agents block sodium channels, preventing neural transmission. Higher concentrations are required to block motor nerves which have the thickest myelin sheath. Full resuscitation facilities such as those found in a properly equipped anaesthetic room must be available prior to commencing neuraxial anaesthesia.
A knotty affair
Published in Southern African Journal of Anaesthesia and Analgesia, 2015
Srivishnu Vardhan Yallapragada, Nagendra Nath Vemuri, Mastan Saheb Shaik
Continuous epidural anaesthesia through a catheter certainly offers the advantage of titrated, safe and prolonged anaesthesia along with a good quality of postoperative analgesia. Epidural catheters can cause some complications and one such rare complication is knotting in the epidural space. Epidural anaesthesia was planned for the arthroscopic repair of a torn anterior cruciate ligament. Intra operative and early postoperative periods were uneventful. However, the epidural catheter was found to be stuck when removal was attempted on the 4th postoperative day. Several attempts were made to retrieve the catheter by applying steady traction under maximal flexion of the back but failed. Finally, under spinal anaesthesia, the catheter was tracked, surgically, along its course up to the epidural space. A knot was observed at the tip of the retrieved catheter. There is a lot of debate in the literature favouring and contradicting the surgical removal of broken fragments of an epidural catheter. However, since the catheter was intact, we attempted removal by surgical dissection of the tract. Broken and lost fragments are better left untouched unless they pose problems and the patients reassured.
Lumbar vertebral hemangioma mimicking lateral spinal canal stenosis: Case report and review of literature
Published in The Journal of Spinal Cord Medicine, 2014
Vasileios Syrimpeis, Vasileios Vitsas, Panagiotis Korovessis
Context Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture. Findings We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful. Conclusion In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended.
Transforaminal epidural steroid injections for the treatment of lumbosacral radicular pain in a Nigeria tertiary hospital: observational study
Published in Southern African Journal of Anaesthesia and Analgesia, 2018
ZA Suleiman, IK Kolawole, BA Ahmed, OM Babalola, GH Ibraheem
Background: Lumbosacral radicular pain is a common cause of chronic low back pain. Despite published reports of effectiveness of transforaminal epidural steroid for lumbosacral radicular pain, it is underutilised in many tertiary hospitals in sub-Saharan Africa. This study assessed the clinical effects of transforaminal epidural steroid injections in patients with lumbosacral radicular pain at a major tertiary health facility in Nigeria. Methods: This is a prospective observational study carried out between March 2012 and February 2016. Under fluoroscopy, the epidural space was accessed through the neuroforamen using 22G spinal needles in 47 adult patients with lumbosacral radicular pain; and a mixture of 10 mg triamcinolone acetonide and 0.25% plain bupivacaine (2 mLs per level) was injected. Pain intensity and functional impairment were assessed with the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI) scores respectively at three and six months. Results: The pain and ODI scores at baseline and at six months’ follow-up improved significantly; 8.49 ± 1.28 vs. 3.6 ± 1.5 (p = 0.002) and 45.1 ± 11.5 vs. 32.4 ± 11.5 (p = 0.001) respectively. Conclusion: Transforaminal epidural steroid injections provided significant pain relief and improved function in patients with lumbar radicular pain due to intervertebral disc herniations.
Related Knowledge Centers
- Spinal Column
- Vertebra
- Spinal Cord
- Dura Mater
- Spinal Canal
- Epidural
- Anatomic Space